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Special Exposure Cohort Petition U.S. Department of HealUl and Human Services

Imder DIe Energy ~1oy.-QQ:upa tionaI Cen8l'a for Disea- ~ aM Pr8-..nIion

~ ~~ Act National kJatlu-. foI:OCQJP8tio n8I Safety and H88IU\

OMS Number: 0920-Q63Q Expires: 05/31/2007

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Special eXDOSure Cohort Petition - Fonn A

Instructions on Completing this Form:

You should use this petition form only if NIOSH has reported to you in writing that it cannot complete the

dose reconstruction needed for your cancer claim.

All other petitioners should use Petition FOm1 B to submit a petition to NIOSH.

For Further Information: If you have questions about these instructions. please call the following NIOSH

toll-free phone number and request to speak to someone in the Office of Compensation Analysis and

Support about an SEC petition: 1-800-356-4674.

A1 NIOSH Tracking Number (Indicated on all NIOSH correspondence):

1A.2 Print Name of Energy Employee for whom this claim was filed:

1A.3

IAtJMrsJMs. Fiat Nan; Middie Initial L8Si NameSocial. Security Number of Energy Employee for whom this claim was filed:

Print and sign your name below to indicate that you are petitioning for HHS to consider adding a cl8881

of employees to the Special Exposure Cohort thai would include the employee indicated by the

tracking number or name under entry 1 above.

~ your name below:' Sij!?your nam..!. below: -- - J ..i

F"nt NaII1e Middle Initial Last N8ne ~First}fame "Middle In~ ::?8tt~~

Once NIOSH receives this form, the U.S. Department of Health and Human Services will consider adding a

class of employees to the Special Exposure Cohort. Your contact at NIOSH will be available to InfOI'm you of

the progress of your petitkm.

Send this form to: SEC Petition

Office of Compensation Analysis and Support

NIOSH

4676 Columbia Parkway, MS-~7

Cincinnati. OH 45226

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Name or Soda! SecurIty Number of First Petitioner;
I Special Exposure COhort Petition

under the EnergyEn1)\oyeesOccupalkJnal

IUnesa Compensation Ad

U.S. Deparbnent of Heatth and Human Services

Ce~rcrDisease~~PI8Y8naon

Nationallnst1tuf8 ill" ~ Safety n HeaUh

OMS Number: 0920-0639 Expires: 05/31/2007

~2~2 S~I~ Ex~ Coh~ Pe~on - F~nn A

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 3 minutes per response.

! including time for reviewing instructions, gathering the information needed, and completing the!onn. If you

i have any comments regarding the burden estimate or any other aspect of this coIlectkJn of information,

Including suggestions for reducing this burden, send them to CDC Reports C1earance Officer, 1600 Clifton

Road, MS-E-11, Atlan1a GA. 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this

address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.

Pets.ons are not required to (e8pond to the information colleded on this form unless it displays a currently

valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the

following:

The Energy Employees Occupations! Illness Compensation Program Act (42 U.S.C. §§ 7384-7385)

(EEOICPA) authorizes the President to designate additional classes of 8mp1oy8es to be Included In the

Special Exposure CohQrt (SEC): EEOICPA authOriZes HHS to implement its responsibilities with the

assistance of the National Institute for OCCupational Safety (NIOSH), an Institute of the Centers for Disease

Control and Prevention. Information obtained by NIOSH in connection with petitions for Including additional

classes of employees in the SEC will be used to evaluat~ the petition and report findings to the Advisory

Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH systelnof records under the

Privacy Act, 09-20-147 .Occupational Health Epidemiotoglcal Studies and EEOICPA Program Records.

HHSlCDClNIOSH.- These records are treated In a confidential manner. unless otherwise oompelied by law.

Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed

below.

NIOSH may need to disclose personal identifying informatiOn to: (a) the Department of Energy, other federal

agencies, otJ)er government .or private entities and to private sector ,el1)plo):e.rs tp ~rrnit ~ en@~ to

retJieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these

individuals can provide Information to assist with the evaluation of SEC petitions; (c) contractors assisting

NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further Investigations;

(e) Fedelal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a

Congressional staff member in response to a verified inquiry.

This notice applies to all forms and infom1ational requests that you may receive from NIOSH in connection lwith the evaluation of an SEC petition. .

Use of the NIOSH petition forms (A and B) is voluntary but your provision of infonnation required by these

forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to

provide required information may not be considered by HHS.

Name or SociaJ Security Number of First Petitioner.